1. Adult Medical-Surgical Nursing
Neurology Module:
Head Injury

2. Head Injury: Classification
Scalp trauma
Skull Fracture:
Linear: simple fracture
Comminuted: fragmented bone
Depressed: dislocated piece of bone pressing into brain tissue
Basilar (basal/base of skull): the paranasal sinus of frontal bone or the temporal bone (allows drainage of blood/ CSF)

3. Brain Trauma: Classification
Coup/ contre-coup: force causes trauma to proximal and distal area of brain
Concussion: temporary loss of consciousness but no structural damage
Contusion: bruising of brain tissue. May have surface brain haemorrhage, oedema (Prolonged LOC, shock, slow recovery)
Diffuse axonal injury: widespread damage to neurons/ cerebral oedema (Coma)

4. Brain Haemorrhage: Classification
Epidural
Sub-dural
Intra-cerebral
Sub-arachnoid

5. Epidural Haemorrhage Arterial
Between the skull bone and dura mater, usually under temporal bone
Emergency as quickly ↑ pressure on brain
Typically LOC, then lucid period (compensation to control ICP) until rapid increase in ICP and deterioration
Requires urgent evacuation via burrhole/ craniotomy: drain left in situ initially

6. Physiological Compensation for Raised ICP
The body attempts to control a rise in intra-cranial pressure through:
Rapid reabsorption of cerebro-spinal fluid
Reduced secretion of CSF
Cerebral vasoconstriction to reduce intravascular volume of cerebral vessels
→ reduced pressure of space-occupation in cranium (and ↓ damage to brain tissue)

7. Subdural Haematoma
Usually venous: collection of blood between dura mater and brain tissue (arachnoid)
Related to coagulopathies, ruptured aneurysm as well as head injury
Acute, sub-acute: related to a major head injury (contusion or laceration)
Chronic: minor head injury, mostly in the elderly, gradually thick fluid → ossification

8. Subdural Haematoma: Clinical Manifestations
LOC
Pupil changes
Hemiparesis
→ Coma, with ↑ BP and pulse pressure, bradycardia, slow respirations
Chronic subdural: slow development: fluctuating headache, paralysis, focal seizures, mental deterioration, personality changes (symptoms appear over time)

9. Subdural Haematoma: Treatment
Surgical evacuation through burrholes or craniotomy if too large

10. Intra-cerebral Haematoma
Bleeding into the brain tissue
Occurs with force over a small area: bullet or missile injury or stab wound
May be inaccessible and difficult to evacuate
Management involves maintaining ICP and stabilising BP: support and maintenance until absorbed

11. Sub-arachnoid Haemorrhage
Haemorrhage, not a haematoma
This is a bleed into the CSF (may be ruptured aneurysm or vascular anomaly as well as trauma)
Blood in CSF blocks flow → hydrocephalus and ↑ ICP
Compression of brain tissue or brain ischaemia and infarct from vasospasm

12. Sub-arachnoid Haemorrhage: Clinical Manifestations
Sudden, severe headache
Loss of consciousness (LOC)
Neck rigidity and pain (meningeal irritation)
Visual loss, diploplia, ptosis
Tinnitus, dizziness, hemiparesis
If slight may seal itself
Coma and death if severe
50% mortality rate

13. Sub-arachnoid Haemorrhage: Treatment
Early repair of damaged vessel (ablation therapy to seal) if possible
Support and maintenance otherwise:
Prevention of complication of vasospasm by calcium channel blocker
Prevention of seizures (Epanutin)
Early dissolving of clot (tPA) to reduce risk of secondary haem: IV volume expanders
Ventriculostomy/ VP shunt if hydrocephalus

14. Head Injury: Nursing Considerations
ICU: ↑ head of bed
Monitor and maintain ICP
Glasgow Coma Scale: level of consciousness
Monitor and maintain vital signs, fluid balance
Care of the unconscious patient
Maintain sterility of dressings and drains
Medications as ordered